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Management of Neurogenic Bladder Disorders. Andrea Staack, MD, PhD Pelvic Reconstructive Surgery, Urinary Incontinence & Female Urology Department of Urology Loma Linda University, CA. What will you learn during the next 20 min?. What is happening to my bladder? How will I get evaluated?

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Management of Neurogenic Bladder Disorders

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Management of neurogenic bladder disorders l.jpg

Management of Neurogenic Bladder Disorders

Andrea Staack, MD, PhD

Pelvic Reconstructive Surgery,

Urinary Incontinence & Female Urology

Department of Urology

Loma Linda University, CA


What will you learn during the next 20 min l.jpg

What will you learn during the next 20 min?

  • What is happening to my bladder?

  • How will I get evaluated?

  • How can I improve my symptoms?

  • Therapy with medication

  • Invasive interventions


What will you learn during the next 20 min3 l.jpg

What will you learn during the next 20 min?

  • What is happening to my bladder?

  • How will I get evaluated?

  • Simple measurements for therapy

  • Therapy with medication

  • Forms of interventions


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1. What is happening to my bladder?

You are not alone!

  • 40-50% in the elderly population will suffer from bladder disease in the U.S.

  • Risk increases with age

  • Can “happen out of the blue” or

  • Can have neurological causes


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1. What is happening to my bladder?

Dual control of urination:

Autonomic nervous system control

Nerve coming from the spinal cord and go directly to the bladder

When bladder gets fuller, signals are sent to the brain

Central nervous system

Voluntary control to choose when to void

Both can be altered by aging or neurological disease


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Friedreich’s ataxia andneurogenic bladder disorder


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Uncontrolled Contraction of the Bladder Muscle

Normal bladder

Patients with urge or frequency

Patients with urge incontinence

Urethral resistance

Uncontrolled bladder muscle contractions


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1. What is happening to my bladder?

Friedreich’s ataxia and neurogenic bladder disorder:

  • More patients will most likely develop incontinence from bladder overactivity than from difficulties to empty bladder

  • Degenerative disease of nerve tissue in the spinal cord and peripheral nerves

  • Exact mechanism of bladder disorders remains unclear


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1. What is happening to my bladder?

  • Overactive Bladder Symptom:

  • “Experiencing a strong urge to go to the bathroom.”

  •  Urinary Urgency


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1. What is happening to my bladder?

  • Overactive Bladder Symptom:

  • “Going to the bathroom frequently.”

  • “Have to go to the bathroom, where the bladder wakes me up at night.”

  •  Urinary Frequency


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    1. What is happening to my bladder?

    • Overactive Bladder Symptom:

  • “Loosing involuntary urine accompanied with the strong desire to void.”

  •  Urge Urinary Incontinence


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    What will you learn during the next 20 min?

    • What is happening to my bladder?

    • How will I get evaluated?

    • Simple measurements for therapy

    • Therapy with medication

    • Forms of interventions


    Slide13 l.jpg

    2. How will I get evaluated?

    “Hello, incontinence helpline – Can you hold?”


    2 how will i get evaluated history l.jpg

    2. How will I get evaluated?-History-

    • Fluid intake pattern

    • Number of continent and incontinence episodes

    • Night time urgency

    • Voiding Pattern

      • Quality of stream

      • Incomplete voiding

    Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.Wyman JF, et al. Obstet Gynecol. 1988;71:812-817.


    2 how will i get evaluated history15 l.jpg

    2. How will I get evaluated?-History-

    • Alterations in bowel habits

    • Changes in sexual function

    • OB/GYN history

    • Medications

    • Neurologic history

      • Back pain, back surgery

      • Stroke

      • Numbness, weakness, balance problems


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    2. How will I get evaluated?-Quantification of symptoms-

    Voiding diary day and night for >24 hours:

    • Document of fluid intake

    • Quantification of urine output with voiding hat

    • Uncontrolled loss of urine at day and night

    • Degree of urge to go to the bathroom

    • Use and number of pads

    Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.


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    2. How will I get evaluated?-Physical examination-

    • General examination

    • Focused neurological examination

    • Genitalia and pelvic floor examination

    • Rectal examination

    Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.


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    2. How will I get evaluated?-Invasive Tests-

    • Urodynamic studies assess:

      • Uncontrolled bladder contractions

      • Urethral competence during filling

      • Bladder function during voiding

      • Left-over urine after urination

    Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.


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    2. How will I get evaluated?

    -Laboratory tests-

    • Urine tests

      • To rule out blood in the urine, kidney problems, urinary tract infections

    • Blood work as appropriate

      • Blood sugar

      • PSA (prostate cancer)

    Fantl JA et al. Agency for Healthcare Policy and Research;

    1996; AHCPR Publication No. 96-0686.


    2 how will i get evaluated invasive tests20 l.jpg

    2. How will I get evaluated?-Invasive Tests-

    • Bladder scanning with a camera (Cystoscopy)

      • To rule out any growth, inflammation, or stones inside the bladder

    • Imaging Studies

      • Ultrasound

      • X-ray studies with contrast fluid during

      • MRI

    Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.


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    What will you learn during the next 20 min?

    • What is happening to my bladder?

    • How will I get evaluated?

    • How can I improve my symptoms?

    • Therapy with medication

    • Forms of interventions


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    3. How can I improve my symptoms?-Dietary changes-

    Adequate fluid intake:

    • Not too much to avoid too frequency

    • Not too little to avoid bladder irritation and urinary tract infections

    • Reduce evening fluids to manage nighttime urination

    1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.


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    3. How can I improve my symptoms?-Dietary changes-

    Certain fluids can irritate the bladder:

    • Carbonated drinks

    • Citrus juices

    • Caffeinated drinks, e.g. soda, tea, coffee

    • Alcoholic beverages

    1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.


    3 how can i improve my symptoms dietary changes24 l.jpg

    3. How can I improve my symptoms?-Dietary changes-

    • Dietary adjustments

      • Fruits

      • Vegetables

      • High fiber intake

    • Bowel regulation

      • Avoid constipation and straining

      • Routine defecation schedule

    1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.


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    3. How can I improve my symptoms?-Lifestyle changes-

    • Stop smoking

      • To reduce chronic coughing reduces downward pressure on the pelvic floor

    • Weight reduction

      • Excessive body weight affects bladder pressure, blood flow, and nerves

    1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.


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    Helps strengthen the muscles of the pelvic floor – improves bladder stability

    Helps suppress the feeling of urgency

    Bladder Relaxation

    3. How can I improve my symptoms?-Exercises-

    Pelvic floor exercise:

    Contraction


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    3. How can I improve my symptoms?-Exercises-

    Kegel exercise for men and women:

    • Find your pelvic floor muscles.

    • Squeeze your pelvic floor muscles as hard as you can and hold them (squeeze 3-5 sec and relax for 5 sec).

    • Do sets of repetitions of squeezing (start with 5 repetitions: squeeze, hold, relax).

    • Increase lengths, intensity, and repetitions every couple of days.

    • Perform Kegel exercises 3-4x during the day.


    3 how can i improve my symptoms l.jpg

    3. How can I improve my symptoms?

    • Biofeedback therapy:

      • Monitors correct muscular contraction to develop conscious control of pelvic musculature

      • Voluntary contraction of the pelvic floor muscles controls urge to urinate


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    3. How can I improve my symptoms?

    Bladder training:

    • Scheduled voiding at set times during the day

    • Active use of muscles to prevent urine loss

    • Increase voiding intervals after the initial goal is achieved

    • Keep own input and output chart

    • Reward increasing volumes of urinary output


    3 how can i improve my symptoms30 l.jpg

    3. How can I improve my symptoms?

    Alternative therapies:

    • Hypnotherapy

    • Yoga

    • Acupuncture


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    4. How can I improve my symptoms?-Summary-

    6 steps for continence:

    • Drink less than 5 glasses/day (40 oz)

    • Stop drinking after dinner

    • Elevate legs

    • Timed voiding

    • Regular pelvic floor exercises

    • Voiding diary


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    What will you learn during the next 20 min?

    • What is happening to my bladder?

    • How will I get evaluated?

    • How can I improve my symptoms?

    • Therapy with medication

    • Forms of interventions


    Slide33 l.jpg

    “Each capsule contains your medication plus a treatment for each of its side effects.”


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    4. Therapy with medication

    Drug Treatment for Overactive Bladder:

    Targets bladder nerves to block uncontrolled contractions

    Anticholinergics

     Not very bladder specific


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    4. Therapy with medication

    Side effects:

    Dry mouth• Tachycardia

    Constipation• Fatique

    Blurred vision • Dizziness

    Slow thinking


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    4. Therapy with medication

    Drug interactions between anticholinergics and:

    Beta-blocker

    Drowsiness

    Dizziness

    Confusion

    Blurred vision

    Amantadine

    Urinary retention

    Dry skim


    What will you learn during the next 20 min37 l.jpg

    What will you learn during the next 20 min?

    • What is happening to my bladder?

    • How will I get evaluated?

    • How can I improve my symptoms?

    • Therapy with medication

    • Interventions


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    5. Interventions-Botox®-

    • Neurotoxin, Clostridium botulinum

    • Injections into the bladder under direct vision

    • Blocks chemically nerve ends

    • As early as 2 days after injections it improves urgency and frequency


    5 interventions botox39 l.jpg

    5. Interventions-Botox®-

    • Duration between 3-6 months

    • Not FDA-approved for neurogenic bladder, but is widely used for failure of medical therapy

    • Not indicated in patients with difficulties to empty their bladders


    5 interventions botox40 l.jpg

    5. Interventions-Botox®-

    Local side effects:

    • Excessive bladder muscle relaxation can cause urinary retention

    • Pain

    • Infections

    • Bleeding

      General side effects:

    • Muscular weakness

    • Less effective during prolonged time

    • Some people build up a resistance


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    5. Interventions-Electrical stimulation of the tibial nerve-

    • Objective alternative to medical therapy

    • Least invasive form of neuromodulation

    • Indirect stimulation of bladder nerves using a nerve at the lower leg

    • Recommended treatment is 12 weekly sessions of 30 minutes each

      Peters KM, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182:1055–61


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    5. Interventions-Sacral Neuromodulation-

    • “Pacemaker for the bladder”

    • Treatment for urgency, frequency, urge incontinence, and urinary retention

    • Proven efficacy in patients for whom more conventional therapy has been unsatisfactory

    • Over 14 years FDA-approved

    • Neurologic diseases -like MS, Parkinson's disease and SCI injuries- are undergoing sacral neuromodulation with good success


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    5. Interventions-Sacral Neuromodulation-

    How does it work?

    • Leads float next to bladder nerves

    • Leads are connected to a battery placed at the buttocks

    • Leads sent mild electrical impulses out to the sacral nerves

    • Can be discontinued at any time


    5 interventions sacral neuromodulation44 l.jpg

    5. Interventions-Sacral Neuromodulation-

    Side effects:

    • Skin irritation

    • Pain

    • Wire movement

    • Device problems

    • Interaction with other devices

    • MRI exam not possible


    5 interventions l.jpg

    5. Interventions

    Surgery:

    • Bladder denervation

    • Bladderaugmentation

      • Bladder becomes enlarged with an extension made out of bowel

      • Larger reservoir with lower bladder pressures


    Slide46 l.jpg

    Your bladder matters!


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    1. What is happening to my bladder?

    Friedreich’s ataxia and neurogenic bladder disorder:

    • Overactive bladder or

    • Poor control of sphincter muscles or

    • Urine retention


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    2. How will I get evaluated?-History-

    Risk factors:

    Previous surgeries

    Back pain

    History of lumbar disc prolapse

    History of other urological or gynecological conditions:

    Bladder prolapse

    Uterine prolapse

    Rectal prolapse


    2 how will i get evaluated history49 l.jpg

    2. How will I get evaluated? -History-

    Excluding secondary causes:

    Diabetes

    Congestive heart failure

    Bladder cancer

    Urinary tract infections

    Pregnancy

    Medications

    Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.


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    Normal Voiding Cycle

    Emptying

    phase

    Filling & storage phase

    Bladder pressure

    Normal desire

    to void

    First sensation

    to void

    Bladder filling

    Bladder filling

    Abrams P, Wein AJ. The Overactive Bladder — A Widespread and Treatable Condition. Stockholm, Sweden: Erik-Sparre Medical AB; 1998.


    2 how will i get evaluated l.jpg

    2. How will I get evaluated?

    Medications That May Influence Bladder Function:

    • Anti-water meds (Diuretics)

    • Antidepressants

    • Blood pressure meds

    • Hypnotics

    • Pain meds

    • Narcotics

    • Sedatives

    • OTC-Sleep aids and cold remedies

    • Antipsychotics

    • Herbal remedies


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    “I’ve reached that age where I’ve given up on

    Mind Over Matter and am concentrating on

    Mind Over Bladder.”


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    2. How will I get evaluated?-Quantification of symptoms-

    • Do you have to rush to the toilet to urinate?

    • Does urine leak before you can get to the toilet?

    • How often do you pass urine during the day?

    • During the night, on average, how many times do you have to get up to urinate?

    • Does urine leak after you feel a sudden need to go to the toilet?

    International Consultation on Incontinence Modular Questionnaire on Overactive Bladder in

    Raz, S and Rodriguez, LV: Female Urology. 3rd ed., 2008


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    2. How will I get evaluated?-Physical examination-

    • Genitalia and pelvic floor examination:

      • Evaluate for uterine, bladder, rectal prolapse

      • Vaginal tissue thinning

      • Cough test

    Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.


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    3. How can I improve my symptoms?

    Program to train yourself at home:

    • Regular Kegel exercise

    • Set up voiding schedule aiming to expanding voiding intervals

    • Active use of muscles to prevent urine loss

    • Dietary changes


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